Refer someone with dementia to Dementia Auckland
To refer someone to Dementia Auckland, you can fill out the online form and submit it electronicaly - or you can use the downloadable PDF Dementia Auckland Referral Form Please print it off, fill it in and fax or post it to us.
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Person living with dementia details or patient label
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Phone Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Age {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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D.O.B {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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NHI Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Diagnosis (type of dementia) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Recent cognitive test results Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Score {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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First Names {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Last Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Ethnicity {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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DOB {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Post Code {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Relationship to person with dementia {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Phone Number Home {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Other relevant information
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Date received by Dementia Auckland {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Services offered
- Information on dementia
- Keyworker support / navigation
- Education courses for carers / families
- Phone consultations
- Support groups for carers
- Activity groups for person with mild to moderate dementia